Journal Article > Commentary

Diagnostic reasoning is a core component of safe care, but its presence as a topic in clinical training is not robust. This commentary recommends a three-element approach to augment clinical education on diagnostic reasoning, which includes focusing on the structure of teaching conferences and rounds, the training environment, and mechanisms to monitor and assess diagnostic reasoning abilities.

Journal Article > Commentary

Health information technologies that effectively use data to understand risk can help identify a patient's likelihood of experiencing insufficient care. This commentary recommends that health care systems utilize risk stratification to ensure patients are appropriately screened and tested for cervical cancer and other diseases as a way to enhance safety.

Journal Article > Commentary

This commentary reviews three mistakes the author made while caring for patients and the different responses regarding disclosure of these errors from peers, patients, and mentors. The author advocates for openly sharing mistakes with others to serve as an opportunity to learn from errors.

Simulation training has been used to develop clinical and nontechnical skills in teams and individuals. This commentary describes an interprofessional simulation program developed to help students learn to manage hierarchy and enhance communication. The authors describe the design and planning of the learning experience and report the results of the effort.

Autopsy is considered the gold standard for finding answers in death investigations. This case report focuses on ethical considerations when forensic pathologists discover a medical error unrelated to the cause of death and how the mistake may be disclosed to the patient's clinical team and family.

Journal Article > Commentary

The promise of health information technology (IT) faces challenges that hinder its effectiveness as a safe, reliable tool. This commentary provides an overview of the revisions to the SAFER Guides and discusses how to use the guides to manage the risks of health IT implementation.

Journal Article > Commentary

The need to improve patient safety is an international concern. This commentary discusses the importance of partnership in reaching the overall goals of global patient safety and highlights experiences in Africa that demonstrate how high-income health care systems can learn from low-income hospitals.

Journal Article > Commentary

Patient safety interventions are not always implemented successfully. This commentary suggests that focusing on change management and the role of middle managers can help optimize the process, foster communication, and model the learning culture required to sustain improvements from safety initiatives.

Journal Article > Commentary

Although video and audio recordings of surgery may be useful in reviewing adverse events, previously used recording devices have only been able to capture a limited amount of data. This commentary describes the development of technology similar to the aviation black box that can collect a rich data set in the operating room for researchers to use to design targeted improvements.

Journal Article > Commentary

Simulation training has been increasingly adopted as a valuable teaching tool. This editorial offers insights from program officers at the Agency for Healthcare Research and Quality regarding questions they consider when deciding on simulation projects to fund. The authors encourage research that could help to formalize the evidence base of this promising learning modality.

Journal Article > Commentary

Insufficient teamwork can exacerbate communication errors and misunderstandings. This commentary explains how sensemaking can enhance communication among team members and describes strategies to promote team sensemaking.

Journal Article > Commentary

Personal experiences can inform understanding of medical error. This commentary describes a physician's experience being sued for malpractice, which involved a pediatric patient with a delayed diagnosis, and insights drawn from being an expert witness in cases after that incident.

Journal Article > Commentary

This commentary describes an AHRQ-funded project to develop an interactive web-based dashboard to communicate patient data in real time to augment safety of care activities. The authors review important functions of the tool, considerations for future development, and initial evaluation results.

Residency programs face barriers to incorporating patient safety and quality improvement learning opportunities into their curriculum. This commentary discusses how to address these challenges in subspecialty training and enhance the experience of trainees in safety and quality skill development.

Journal Article > Commentary

Performance standards in surgical care range from those tracking technical competencies to hospital volume. Reviewing various ways to assess surgical skill such as video review and how nontechnical skills like communication and situational awareness can affect surgical performance, this commentary highlights the challenges to aligning rating scales with surgical outcome measures.

Journal Article > Commentary

Transparency in the reporting of quality and safety data demonstrates a commitment to improvement, learning, and patient empowerment regarding provider selection. This commentary suggests potential standards for hospitals to adopt for public reporting of their quality data and advocates for an external entity that reports how hospitals adhere to public reporting of quality measures.

Journal Article > Commentary

A culture of organizational professionalism supports a safe environment for patients and health care providers. This commentary describes the development of guidance to help organizations foster partnerships with patients and the community, establish a collective mindset across the organization, and create the infrastructure required for safe care delivery.